MEDICARE: MS. CHARAUN BOLTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2278P3800X	Palliative/Hospice Certified Respiratory Therapist
2	253Z00000X	In Home Supportive Care Agency
3	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility
4	323P00000X	Psychiatric Residential Treatment Facility
5	376J00000X	Homemaker
6	385H00000X	Respite Care
7	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	152180	PA

General Provider Information

NPI Number	:	1851197248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHARAUN BOLTON

Provider Business Mailing Address
First Line	:	7262 CORNELIUS ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19138-1618
Country	:	US
Telephone Number	:	267-997-2490
Fax Number	:

Provider Business Practice Location Address
First Line	:	5131 DIAMOND ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-2314
Country	:	US
Telephone Number	:	267-997-2490
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2025
Last Update Date	:	06/24/2025

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